Dr Richard Peevor comments on the new SIGN guideline and its support for the role of multidisciplinary care for patients

In the developing world, cervical cancer remains the most common cancer of women, with 471,000 new cases diagnosed in 2000 and over 233,000 deaths worldwide.1 The introduction of a national screening programme in the UK was responsible for a 42% reduction in the incidence of cervical cancer from 1988 to 1997,2 which exceeded all expectations. Screening is thought to save 4500 lives per year in England.3

However, in 2004 in the UK there were 2726 new diagnoses of cervical cancer, and 1061 patient deaths from the disease during 2005.4 The majority of cases of cervical cancer in the UK are diagnosed in patients who have defaulted from, or who have never attended, the screening programme; of those women under 70 years with cancer, only 47% had an adequate screening history.5

Each year, over 4 million patients in the UK are invited for cervical screening,4 but recent trends have shown fewer women are accepting these invitations, with a more significant decrease seen in the 25–29 year old age group, which fell from 77% in 2000 to 68.2% in 2007 in England.6 It has been postulated that this reduction may be related to the reduced prevalence of the disease and thus a seeming lack of importance of attending screening.

Human papillomavirus vaccination

Vaccination against two of the high-risk strains (16 and 18) of the causative agent, human papillomavirus (HPV), could potentially prevent up to 70% of cervical cancers, reducing the incidence of cervical cancer still further.7 It is crucial for healthcare professionals and patients to be aware that the vaccines currently available will have no effect on 25–30% of cervical cancers, which are caused by other HPV subtypes.

The planned implementation of prophylactic HPV vaccination in the UK in September 2008 must therefore include patient education, stressing the importance of attending for cervical screening when invited, despite having been vaccinated.8

About the new guideline from SIGN

The Scottish Intercollegiate Guidelines Network (SIGN) guideline on the Management of cervical cancer7 is evidence based and was produced by a multidisciplinary group of clinicians. Much of the guideline refers to care within tertiary referral centres, but there are several areas that will be useful to clinicians in primary care.7

Appropriate, timely referrals may be improved by following the algorithm produced by SIGN for the investigation of postcoital bleeding (PCB), which triages patients and indicates the importance of testing for Chlamydia trachomatis. Testing for C. trachomatis is also discussed in relation to the investigation of other types of abnormal vaginal bleeding.

Although the guideline is detailed, there is little guidance relating to the urgency of referrals from primary care and the timescales for management thereafter; particularly with reference to meeting 31- and 62-day targets for making a diagnosis and initiating treatment.7

Cervical smear tests

The guideline reaffirms that: ‘A systematic review identified no evidence to support performing a smear when a woman presents with PCB if the smear is not due.’7

The cervical screening smear is designed to pick up asymptomatic pre-invasive disease of the cervix, and it is important to remember that cervical smears are designed to be used within a screening programme and should not be used as a diagnostic test.

Clinical management

Details in the SIGN guideline of clinical management following initial referral may well be of use to GPs when seeing patients in the primary care setting. Some patients are overwhelmed by the information given to them during their hospital visit and retain very little; referring to the guideline may help GPs answer questions put to them by patients and help to clarify any confusion.

Role of the multidisciplinary team

It is encouraging to see a large part of a clinical guideline devoted to the importance of multidisciplinary care of cancer patients. The role of the multidisciplinary team (MDT) is described, but sections are also devoted to other important topics, often previously omitted by guidelines and reviews. These include:7

  • detailed review of the huge psychosexual and psychosocial issues
  • assessment and management of associated problems, such as radiation-induced dyspareunia, loss of libido, loss of fertility, premature menopause, and lymphoedema
  • good practice points relating to communication with patients—in particular the importance of a clinical nurse specialist for all newly diagnosed patients
  • listings of patient resources, including cervical cancer support groups and cancer charities, both locally in Scotland and across the UK
  • management of complications in advanced disease—this is dealt with in a chapter of its own, and will be useful to GPs caring for patients in the palliative setting. Topics covered include pain control, thrombosis, vaginal bleeding, fistulae, malodour, and renal failure.

Implementation of the guideline

The SIGN guideline documents the evidence behind current practices, which tend not to differ greatly from centre to centre, and will make implementation of the majority of the guideline straightforward.

Tertiary centres are already working in a multidisciplinary way, with all members of the team involved in decision making. The MDT meetings allow immediate review of data, such as laboratory results, pathology, radiology, and access to databases. The use of MDT databases helps to improve care by facilitating clinical audit.

Following discussion in an MDT meeting, appropriate follow up of patients and referrals between specialities can often be organised immediately by the MDT clerical staff, thereby streamlining the care pathway.

Barriers to implementation

Difficulties with implementing the SIGN guideline in the UK may occur in connection with several aspects of care. These are:

  • the availability of positron emission scanning as part of initial investigation and staging
  • the lack of a consensus opinion with regard to fertility-preserving surgery and its availability, which is limited.

Consultants remain divided in their opinions on and enthusiasm for radical trachelectomy in early stage disease management. With the small numbers of patients suitable for trachelectomy, such operations should be undertaken by teams in quaternary centres with appropriate experience and throughput of patients to maintain standards.

In future years, as a consequence of screening and prophylactic vaccination, it is likely that the numbers of cases suitable for operation will continue to fall, which may lead to further regionalisation of care.

Conclusion

This new guideline from SIGN7 is a well written and easily accessible resource that will improve the clinical management, the provision of care, and particularly the support networks available to cervical cancer patients and their families.

Acknowledgement

The author would like to thank Professor Alison Fiander for reviewing the manuscript.

  1. Yang, B, Bray F, Parkin D et al. Cervical cancer as a priority for prevention in different world regions: an evaluation using years of life lost. Int J Cancer 2004; 109 (3): 418–424.
  2. National Statistics. Health Statistics Quarterly 07. Autumn 2007. London: The Stationery Office, 2007.
  3. Peto J, Gilham C, Fletcher O, Matthews F. The cervical cancer epidemic that screening has prevented in the UK. Lancet 2004; 364 (9430): 249–256.
  4. Cancer Research UK. Cited 2008; Available from: http://info.cancerresearchuk.org/cancerstats/types/cervix/?a=5441
  5. Sasieni P, Cuzick J, Lynch-Farmery E. Estimating the efficacy of screening by auditing smear histories of women with and without cervical cancer. The National Co-ordinating Network for Cervical Screening Working Group. Br J Cancer 1996; 73 (8): 1001–1005.
  6. National Statistics, The Information Centre. Cervical Screening Programme, England. 2006–07. London: The Information Centre, 2007.
  7. Scottish Intercollegiate Guidelines Network. Management of cervical cancer. A national clinical guideline. Edinburgh: SIGN, 2008.
  8. http://www.gnn.gov.uk/environment/fullDetail.asp?ReleaseID=325799&NewsAreaID=2G